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hot & spotty #2…

October 14, 2013 By Christopher Partyka Leave a Comment

the case.

A 14 year old boy is bought to ED with a 4 day history of fevers. His parents are concerned as this rampant red rash has rapidly spread across his body overnight…. [Read more…]

Filed Under: Dermatology, Infectious Disease, Paediatrics Tagged With: conjunctivits, coryza, cough, koplik spots, measles, morbilliform rash, paramyxovirus, vaccine

straightening the spiral…

September 28, 2013 By Christopher Partyka Leave a Comment

the case.

a 2 year old male is carried into your ED screaming. He is horribly distressed and trying to reach down to grab at his right thigh. His parents report that he was standing outside watching his older brother ride his bike. He was knocked over in the process and his right leg ‘twisted around’ in the process. [Read more…]

Filed Under: Orthopaedics, Paediatrics, Radiology Tagged With: femoral nerve block, fracture management, midshaft femur, non-accidental injury, paediatric femur fracture, Pavlik Harness, pediatric femur fracture, Spica cast, spiral fracture

hot & spotty…

September 23, 2013 By Christopher Partyka Leave a Comment

the case.

A mother brings her 18 month old child to your emergency department with a 24 hour history of fevers. She is now worried that her daughter has developed these little red spots.

[Read more…]

Filed Under: #FOAM, Dermatology, Infectious Disease, Paediatrics Tagged With: coxsackievirus, enterovirus A16, febrile rash, hand foot and mouth, HFM, paediatric rash, viral exantham

more knackered neonates…

August 5, 2013 By Christopher Partyka Leave a Comment

Following on from our first knackered neonate – here are some rapid fire cases of unwell little ones… [Read more…]

Filed Under: Interesting, Paediatrics Tagged With: congenital diaphragmatic hernia, neonatal resuscitation, pneumothorax, pyloric stenosis, respiratory distress, sick neonate, transient tachypnoea of newborn, TTN

a knackered neonate…

July 20, 2013 By Christopher Partyka Leave a Comment

the case.

You are working in a district hospital and are called to the Special-Care Nursery to assist with an unwell newborn infant.

She was born 2 hours ago at 39 + 4 weeks gestation, to a primip mother who reports a completely unremarkable pregnancy and normal antenatal investigations (including morphology scans). The child has had marked respiratory distress and hypoxia since birth… [Read more…]

Filed Under: Airway, Anaesthesia/Analgesia, Paediatrics, Radiology Tagged With: airway, CCAM, DOPE mnemonic, foetal lung interstitial tumour, neonatal intubation, neonatal resuscitation, respiratory distress, RSI

slip and fall…

April 1, 2013 By Christopher Partyka Leave a Comment

The Case.

A young boy is bought to your ED with an obviously swollen painful left arm after a slip and fall…

These are his xrays…

Swollen&Painful (lat)             Swollen&Painful (AP)

Describe this injury…

Type III Supracondylar Fracture, with posteromedial displacement.

Supracondylar Fracture – Tell me more…

Supracondylar Fracture

  • The most common paediatric elbow fracture.
  • Typically occurs in kids < 8 years of age.
    • This is a result of the ligament/joint capsule tensile strength being greater than that of the bone itself.
  • Extension vs Flexion:
    • Extension:
      • >95% of all supracondylar fractures are extension related.
      • Olecranon forcefully driven into olecranon fossa.
      • Results in failure of anterior cortex & displacement of distal fragment posteriorly.
      • Can be further defined by the Gartland Classification.
    • Flexion:
      • Energy transferred from posterior aspect of proximal ulna to distal humerus.
      • Anterior displacement of the distal fragment and failure of cortex posteriorly.

The Gartland Classification.

  • Type 1: Non-displaced.
  • Type 2: Displaced fracture with intact posterior cortex.
  • Type 3: Displaced fracture with no cortical contact.
    • A: Posteromedial rotation of the distal fragment.
    • B: Posterolateral rotation of the distal fragment.

An approach to the Paediatric elbow X-ray…

Firstly, we should recall the ossification centres of the elbow & the helpful mneumonic “CRITOE”.

Critoe Table

CRITOE

taken from *http://www.wikem.org/wiki/Elbow_X-ray_(Peds)

The Anterior Humeral Line.

  • On a normal lateral elbow x-ray, a line drawn along the anterior surface of the humerus should pass through the middle third of the capitellum.
  • If the capitellum falls posteriorly to this line, an extension-type supracondylar fracture is likely…

anterior humeral line

taken from *http://www.radiologytutorials.com

Abnormal Anterior Humeral Line

An abnormal anterior humeral line – taken from *http://www.radiologyassistant.nl/en/p4214416a75d87

The Radiocapitellar Line.

  • A line drawn along the radial neck should intersect the capitellum.
  • Failure to do so, suggests a radial head dislocation.
  • For great examples see RadiologySigns – Three children with elbow pain… or Radial Head Dislocation @ Youtube.com

Fat Pads.

  • An anterior fat pad protrudes from the Coronoid fossa.
    • It is normal unless bulging or shaped ‘like a sail’.
  • A posterior fat pad is always pathological.
Ant&Post Fat Pads
Adapted from wikimedia.org

Baumann’s Angle.

  • An additional aid for diagnosing subtle supracondylar fractures.
  • Angle is formed by a line drawn along the growth plate of the capitellum that transects a line running along the axis of the humerus.
  • It should be ~ 75 degrees.

Baumanns Angle

Left is normal. Right is obviously not...

What not to miss…

Neurovascular compromise occurs in up to 49% of all Type III injuries.

    • Median nerve:
      • Involved in 50% of cases.
      • Associated with posterolateral displacement.
    • Radial nerve:
      • Involved in 1/3 of cases.
      • Associated with posteromedial displacement.
    • Brachial artery:
      • Includes entrapment, laceration, intimal tear or compression (compartment syndrome).
      • Approximately 40% of cases.
      • Found in either medial or lateral displacement.

Be on the lookout for Compartment Syndrome.

    • Pain on flexion or extension of fingers
    • Forearm tenderness on palpation.
    • Disproportionate pain to injury.
    • Important as unrecognised ischaemic injury can result in Volkmann’s Ischaemic Contracture.

Management in the ED…

  • Obviously, a limb with neurovascular compromise mandates immediate reduction.
    • Delay to the operating theatres may require a reduction attempt in the ED. Rosen’s demonstrates this manoeuvre quite well.
  • Type I injuries;
    • Splint in ED (aim for 90 degrees of elbow flexion, with neutral rotation).
    • Outpatient referral to Orthopaedics is appropriate.
  • Type II injuries;
    • No current consensus with regards to surgical management.
    • Closed reduction & plaster vs ORIF.
    • Referral to Orthopaedics at let them decide.
  • Type III injuries.
    • Urgent Orthopaedic consultation –> OT for closed reduction, pinning or ORIF.
    • Splinting for comfort.
    • Thorough and repeated neurovascular examination.

References.

  1. Rosenʼs Emergency Medicine. Concepts and Clinical Approach. 7th Edition
  2. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th Edition.
  3. The Royal Children’s Hospital Melbourne; Clinical Practice Guideline on Supracondylar Fractures.

Filed Under: Orthopaedics, Paediatrics, Radiology Tagged With: anterior humeral line, Baumann's angle, CRITOE, fat pad, Gartland, humeral fracture, paediatrics, radiocapitellar line, supracondylar fracture, Volkmann's contracture

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